0104-057 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
'Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
D CV) LicenseA Lic. Oass Exp. Date
Lo
a.is Inc; 110..;
Dat Signature of Conh ado.
OWNER -BUILDER DECLARATION.
J I hereby affirm under penalty of perjury that I am exempt,from the Contractor's
L
License Law for the following reason:
( -) 1, as owner, of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owhe�r ot the prupuity, and exclusively tuiih'8LtAii1g with licienced
contractors to construct the project (Sec. 7044, Business & Professionals
ic6de). , *.
<•')I am exempt under Section B&P.C. for this reason
LO
Date Signature of Owner
?Q WORKER'S COMPENSATION DECLARATION
Z
-I hereby. affirm under penalty of perjury one of the following declarations:
0 1 have_ and will maintain a certificate of consent to self -insure for workers'
j .L=, corripensation, as, provided for by Section 3700 of the Labor Code, for the
I _J
performance of the work for which this permit is issued.
I have and will maintain workers' compensation' insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
1-- permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
0 STATE 00MMKOATA'
< (This section need not be completed if the permit valuation is for $100.00 or less).
_J
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers; compensation laws of California" and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code I shall-f6-rtQth Comply with
tKo is.
h 5� prov Sion -
Dat Applir., 14, ;9 1 "1
Applicant
Warning: Failure to secure Workers' Compensafion coverage is unlawful and
shall subject an employer to. criminal penalties and civil fines Up to $100,000, in
addition to'the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject* to the conditions and restrictions set forth on his
application.
1. Each person, Upon whose behalf this application is.made & each person at
wh6se request and for whose benefit work is. performed under or pursuant to,
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City. of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work, is not commenced within180 days from date of issuance of such
permit, or cessationof work f6r .180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned.p,�o
_p for inspection purposes.
i
S , t—(Owner/Ages SignaOre UZ, Date AV
7
BUILDING PERMIT PZ�
DATE VALUATION LOT TRACT
;-A
JOB SITE APN
ADDRESS
70 -W -S MITH WAY
I -
OWNER CONTRACTOR /DESIGNER EN INFER
CEHMRIV Ct. 1:J1.X)rddA roat's & ST'As pol) MAIT
I 5;3f; uo. VIWMMZ MONO 74725J0NXD1a'VT,,=.T,,#A -
S" BY M.1,1TUTIT CA 92260
K.RWARDINC) CA 924-0.8 PALM
0.60)340-9000 r1l"9119 ;JL15
USE OF PERMIT
P0011 AMY911 111MA,
POWASPA A3,.kRMSMARR,1 US BE IW' P1.e.C9,AT P=,PJL&S1r?,R
OXOPP-MION. 00OX, EQUIPMEN'r EaTO'Low.m. N.,oT Immamf)"
FMA, ANTX0R'11JPA
npaov 'L's
D
FSPR 11 2001
CITY OF LA QUINTA
FINANCE DEPT
M
AY415 P] " 011MIK
lZR9, - P '_R_r1,4-1AU) FES
Piauffr "11IMS.VVIE, Now
BY I DATE FINALED I INSPECTOR
KUKKARY
$132,10
r-CYNSTRUCTIOM FErt
101-000-416-00
$2301.00
MCCILANICItL F"111 P0011
101--000-421-000
$241.00
ELIXTIUCA-LY22 -- P0011
101-00".20-000
S4 IN - (9)
MUMBR40 11FIR, _-POOL,
$27AD
D
FSPR 11 2001
CITY OF LA QUINTA
FINANCE DEPT
M
AY415 P] " 011MIK
lZR9, - P '_R_r1,4-1AU) FES
Piauffr "11IMS.VVIE, Now
BY I DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall !
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment location
Underground Electric
Underground Plbg. Test
_
Final
Gas Piping
,
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
1
Appliances
Final
_
J /
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
' Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)